In South Africa, academic and/or anatomical pathology autopsies are conducted in terms of the Human Tissue Act (Act 65 of 1983).

Specialist, Forensic Pathology Service Pretoria and Senior lecturer, Department of Forensic Medicine, University of Pretoria

Lorraine du Toit-Prinsloo is responsible for
conducting medico-legal investigations of death including scene visits,
performance of autopsies and providing testimonies in court. She is
involved in the co-ordination of the academic programme in the
department and teaching of undergraduate and postgraduate
students.

Gert Saayman, MB ChB MMed(MedForens)(Pta) FCForPath(SA)

Chief Specialist, Forensic Pathology Service
Pretoria; Professor and Head, Department of Forensic Medicine,
University of Pretoria

Gert Saayman is responsible for supervising and
providing forensic pathology services in Pretoria and the northern
region of Gauteng. This includes the medico-legal
investigation of all cases of homicidal, suicidal
and accidental deaths, as well as deaths which are sudden,
unexpected or unexplained. He routinely advises the police and
prosecuting authorities in forensic medical matters and acts as expert
witness in inquests and in criminal and civil legal
proceedings.

Autopsies (from the Greek word autopsia, meaning
‘to see with one’s own eyes’), have been performed
for centuries, in one form or the other, to learn about the form and
inner workings of the human body and to ascertain the cause of death in
deceased individuals.1 In time, two distinct settings for the autopsy have developed, with academic or anatomical pathology autopsies
being conducted in order to establish the nature and extent of
underlying natural disease, but also to enable academics to teach
students and to perform research. On the other hand, medico-legal autopsies
are routinely performed in terms of statutory provisions which mandate
the examination of bodies of deceased individuals who have died as a
result of other than natural causes (or where the cause of death is not
apparent or of an unexpected nature), in order to facilitate further
legal decisions and proceedings.

In South Africa academic and/or anatomical pathology autopsies are
conducted in terms of the Human Tissue Act (Act 65 of 1983). In these
cases the attending physician and/or pathologist should be satisfied
that the following two preconditions have been met prior to undertaking
the autopsy: that the deceased had probably died as a result of natural
causes and that consent has been obtained
for the postmortem examination to be performed. If there is a
reasonable possibility that death had been the result of other than
natural causes, the matter should be reported to the police for further
investigation in terms of the Inquests Act (Act 58 of 1959). However,
where the attending clinician is satisfied that death was due to
natural causes, he or she may issue such a certificate, despite not
knowing with certainty what the pathological diagnosis is. In such
cases it may be prudent to request an anatomical pathology autopsy.
Permission to perform an academic/anatomical pathology autopsy may be
obtained from the deceased before his or her death or in terms of a
will, or from his next of kin, after death has taken place. It is worth
noting that the Human Tissue Act is currently in the process of being
revised and will in all probability soon be incorporated into the
National Health Act.

Anatomical pathology autopsy

Anatomical pathology autopsies provide an opportunity to fully
investigate the nature and extent of disease, associated complications
and co-morbid conditions, and as such the autopsy is an excellent tool
to inform clinicians and to arrive at a clinico-pathological
correlation.2
It may also provide valuable information for the next of kin and
closure in cases of uncertainty, as well as providing information which
may be of benefit to surviving family members (siblings and children,
in cases of certain familial disease).

In addition, the regular performance of anatomical autopsies
provides excellent opportunity for individual and institutional quality
control and clinical audit.3
Many published articles have shown that, despite recent advances in
medical technology and diagnostic capacity, significant discrepancies
still exist between clinical diagnosis and diagnosis made at autopsy.
The incidence of significant differences between autopsy findings and
clinical diagnosis varies between 20% and 40%, suggesting that in one
or two out of five deceased individuals upon whom autopsies are
performed, the main clinical diagnosis is not confirmed or supported at
autopsy. 4

It has been said that clinicians and health care institutions
avoid requesting anatomical pathology autopsies, since such missed (or
wrong) diagnoses may constitute grounds for subsequent litigation
and/or legal proceedings. Interestingly, a review of 99 Appeals Court
decisions in medical malpractice cases has shown that such proceedings
were not instituted on the basis of autopsy findings, but rather on
standard of care issues – and that the performance of an autopsy
is not likely to precipitate malpractice proceedings.7
Indeed, it may be that the medical profession (individually and
collectively) will be better served if autopsies are requested more
often in cases where some uncertainties pertaining to diagnosis may
exist. It has been argued that healthcare institutions should be
subjected to prescribed minimum autopsy rates on patients dying within
such institutions, in order to retain accreditation. Such enforced
regulatory practices are probably not advisable, but the profession as
a whole may be well advised to implement logistic and administrative
measures, to facilitate the performance of anatomical pathology
autopsies on a more regular basis. Funding for such examinations could
come jointly from contributions made by the state, medical aid and
insurance companies, hospital budgets (state and private sector) as
well as from doctors (or their indemnity organisations) and patients.

It has been stated that congenital cardiac abnormalities account for
up to 90% of cardiac diseases in children and although the causes are
multifactorial, genetic causes do play a role in some instances.8
In such cases autopsy may be of great value to parents and siblings.
Unfortunately, the recent economic downturn has resulted in severe
financial cutbacks and health expenditure constraints, further limiting
resources which may previously have been available for services such as
autopsies.

In Massachusetts General Hospital the autopsy rate for the first
five decades of the previous century varied between 20% and 40% of
patients who died in the hospital. During the sixth and seventh decades
this figure rose to 50%. However, it has subsequently dropped to a
figure of 13%.1
This decline in the autopsy rate (which indeed appears to be a
universal phenomenon) does not only compromise clinical audit and
diagnostic verification, but seriously compromises the teaching of
under- and postgraduate students, both in terms of the teaching of
autopsy practice and technique as well as in the macroscopic and
microscopic diagnosis of disease conditions.

Medico-legal postmortem examinations

These examinations are conducted primarily in terms of the Inquests
Act, as part of the medico-legal investigation of deaths which may have
been due to other than natural causes. The latter concept (‘other
than natural death’) has only recently been defined in terms of
statute in the Regulations Regarding the Rendering of Forensic
Pathology Services (Government Gazette, R341), promulgated in terms of
the National Health Act (Act 61 of 2003). These regulations
further define an autopsy as ‘a post mortem dissection of a
corpse’ and define postmortem examination as ‘an
examination of a human body or the remains thereof, with the purpose of
establishing the cause of death and factors associated with the death
and may include an autopsy’. In terms of these statutory
provisions, unexpected or unexplained deaths should be investigated in
conjunction with the police, although such investigation may not
necessarily include the performance of an autopsy. In cases where the
attending physician is satisfied that the death had been due to natural
causes, although the precise nature and/or extent of disease or
complication may be obscure, a certificate of natural cause of death
may be issued, although it would then be advisable to request an
anatomical pathology autopsy to be conducted.

Medico-legal autopsies are preformed in terms of prescribed
statutory provisions, with no consent being required from the next of
kin and may only be performed by authorised medical practitioners (who
have been specifically appointed to perform such examinations).
Unfortunately, the huge burden of non-natural death cases which have to
be thus examined annually in South Africa (due to our exceptionally
high levels of interpersonal violence, road traffic fatalities and
accidental as well as suicidal deaths), cannot be adequately handled by
the relatively small number of qualified forensic pathologists. It has
been estimated that some 70 000 medico-legal autopsies must be
carried out annually in South Africa. It is inevitable that many
thousands of these autopsies will be conducted by colleagues who have
little or no formal training in autopsy pathology and technique. In
addition, poor facilities and the lack of other resources (such as a
modern forensic toxicology service) unfortunately contribute to many
instances where the judicial and administrative processes surrounding
death (including, for example, life insurance policy pay-outs and
winding up of estates) are compromised.

The retention and use of tissues obtained at postmortem examination
has become a very contentious matter and is governed by the Human
Tissue Act (for anatomical pathology postmortem examinations) and by
the Inquests Act and the Criminal Procedure Act (for medico-legal
postmortem examinations). The Health Professions Council of South
Africa prescribes that a medical practitioner may use organs or tissues
‘only for research, educational, training or prescribed
purposes’ and that the retention of these organs shall be subject
‘to the express written consent given by the patient concerned
during his or her lifetime; in the case of a minor under the age of 14
years, to the written consent of such minor’s parent or guardian;
or in the case of a deceased patient who had not previously given such
consent, to the written consent of his or her next of kin or the
executor of his or her estate’ (Ethical and Professional Rules of
the Health Professions Council of South Africa, Government Gazette
R717/2007). However, the Human Tissue Act also provides that the
Director-General of Health may give consent to the use of human tissue
obtained at autopsy, for purposes of research, training and preparation
of diagnostic or therapeutic substances, if certain prescribed
conditions have been met. Where it is important to retain tissues
and/or organs at the time of performing an anatomical pathology
autopsy, it is imperative that the next of kin be accordingly informed
and that appropriate consent be obtained −
and that appropriate further management of the remains be stipulated,
also with regard to subsequent disposal of such tissues. This may be
particularly important in cases where ‘emotive’ organs or
tissues (such as heart, brain, eyes, etc.) may be involved.9

It is clear that a concerted effort is required to prevent the
continued decline of the anatomic pathology autopsy as a valuable tool
for purposes of diagnostic audit, clinico-pathological correlation, for
teaching and training of medical students and for purposes of research.
However, new and alternative techniques should increasingly also be
considered in this regard. Sophisticated CT scanning and MRI technology
have contributed to the development of the ‘virtopsy’,10
whereby invasive techniques or dissection are replaced by sophisticated
postmortem imaging techniques. In many instances the latter can be
augmented by the use of limited autopsy techniques (such as acquisition
of postmortem needle samples and aspirations). In addition,
‘molecular autopsies’ are becoming increasingly useful, in
order to assist in the diagnosis of non-structural disease processes
which may be difficult to diagnose by conventional autopsy technique.

To conclude, the autopsy remains a very valuable yet under-used tool
in South Africa. To quote Atul Gawande: ‘I want to think that my
patient’s condition is as predictable as the sun’s rising,
as the melting of an ice cube, and maybe I have to. But I have been
around long enough to know that in human beings the simplest
certainties can be dashed. Whether with living patients or cadavers, we
do not know, until we look.’11

References

1. Mark E. The state and use of autopsy around the world. Symposium 11.
Who wants autopsies and who does not ─ lessons learned from the rise
and fall of the autopsy over the past 100 years. Histopathology
2002;41(Suppl. 2):197-213.

1. Mark E. The state and use of autopsy around the world. Symposium 11.
Who wants autopsies and who does not ─ lessons learned from the rise
and fall of the autopsy over the past 100 years. Histopathology
2002;41(Suppl. 2):197-213.

9. Underwood JCE. Public attitudes to the autopsy and organ retention:
lessons learned from the UK experience. The state of autopsy around the
world. Histopathology 2002;41(Suppl.2):197-213.

9. Underwood JCE. Public attitudes to the autopsy and organ retention:
lessons learned from the UK experience. The state of autopsy around the
world. Histopathology 2002;41(Suppl.2):197-213.

10. www.virtopsy.com (accessed 22 September 2011).

10. www.virtopsy.com (accessed 22 September 2011).

11. Gawande A. Medical dispatch final cut: Medical arrogance and the
decline of the autopsy. The New Yorker Magazine, 17 March 2001.

11. Gawande A. Medical dispatch final cut: Medical arrogance and the
decline of the autopsy. The New Yorker Magazine, 17 March 2001.

IN A NUTSHELL

• Anatomical pathology autopsies are performed
in terms of the Human Tissue Act to establish the nature and extent of
underlying natural disease and to teach and train healthcare
professionals. Specific consent is required.

• Medico-legal autopsies are conducted in
terms of (primarily) the Inquests Act and are mandated by law, thus
requiring no consent from next of kin.

• There has been a substantial drop in the
numbers of anatomical pathology autopsies in most countries, which may
adversely affect teaching, research, diagnostic audit and, ultimately,
patient care.

• Studies have shown that there are still
significant discrepancies between clinical and autopsy diagnoses.
Academic autopsies thus provide an excellent tool for individual and
institutional audit and quality control.

• There should be strict adherence to legislative and ethical guidelines when retaining organs or tissues at autopsy.

• Sophisticated radiological techniques,
together with other technological advances and investigative tools, can
now be used to augment or replace conventional autopsy dissection in
some instances.